Skip to main content
×
×
Home

Change in anxiety following successful and unsuccessful attempts at smoking cessation: cohort study

  • Máirtín S. McDermott (a1), Theresa M. Marteau (a2), Gareth J. Hollands (a2), Matthew Hankins (a3) and Paul Aveyard (a4)...
Abstract
Background

Despite a lack of empirical evidence, many smokers and health professionals believe that tobacco smoking reduces anxiety, which may deter smoking cessation.

Aims

The study aim was to assess whether successful smoking cessation or relapse to smoking after a quit attempt are associated with changes in anxiety.

Method

A total of 491 smokers attending National Health Service smoking cessation clinics in England were followed up 6 months after enrolment in a trial of pharmacogenetic tailoring of nicotine replacement therapy (ISRCTN14352545).

Results

There was a points difference of 11.8 (95% CI 7.7-16.0) in anxiety score 6 months after cessation between people who relapsed to smoking and people who attained abstinence. This reflected a three-point increase in anxiety from baseline for participants who relapsed and a nine-point decrease for participants who abstained. The increase in anxiety in those who relapsed was largest for those with a current diagnosis of psychiatric disorder and whose main reason for smoking was to cope with stress. The decrease in anxiety on abstinence was larger for these groups also.

Conclusions

People who achieve abstinence experience a marked reduction in anxiety whereas those who fail to quit experience a modest increase in the long term. These data contradict the assumption that smoking is a stress reliever, but suggest that failure of a quit attempt may generate anxiety.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Change in anxiety following successful and unsuccessful attempts at smoking cessation: cohort study
      Available formats
      ×
      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Change in anxiety following successful and unsuccessful attempts at smoking cessation: cohort study
      Available formats
      ×
      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Change in anxiety following successful and unsuccessful attempts at smoking cessation: cohort study
      Available formats
      ×
Copyright
Corresponding author
Máirtín S. McDermott, Florence Nightingale School of Nursing and Midwifery, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London SE1 8WA, UK. Email: mairtin.mcdermott@gmail.com
Footnotes
Hide All

Declaration of interest

P.A. has done consultancy and research on smoking cessation for pharmaceutical companies.

Footnotes
References
Hide All
1 Fidler, JA, West, R. Self-perceived smoking motives and their correlates in a general population sample. Nicotine Tob Res 2009; 11: 1182–8.
2 Royal College of Physicians. Nicotine Addiction in Britain: A Report of the Tobacco Advisory Group of the Royal College of Physicians. Royal College of Physicians, 2000.
3 Parrott, A. Stress modulation over the day in cigarette smokers. Addiction 1995; 90: 233–44.
4 DiFranza, JR, Wellman, RJ. A sensitization-homeostasis model of nicotine craving, withdrawal and tolerance: integrating the clinical and basic science literature. Nicotine Tob Res 2005; 7: 9.
5 Parrott, A. Does cigarette smoking cause stress? Am Psychol 1999; 54: 817–20.
6 Kassel, JD, Stroud, LR, Paronis, CA. Smoking, stress and negative affect: correlation, causation and context across stages of smoking. Psychol Bull 2003; 129: 270.
7 Hajek, P, Taylor, T, McRobbie, H. The effect of stopping smoking on perceived stress levels. Addiction 2010; 105: 1466–71.
8 Office of National Statistics. Opinions Survey Report No. 40: Smoking-Related Behaviour and Attitudes, 2008/09. Office of National Statistics, 2009.
9 Dickens, GL, Stubbs, JH, Haw, CM. Smoking and mental health nurses: a survey of clinical staff in a psychiatric hospital. J Psychiatr Ment Health Nurs 2004; 11: 455–1.
10 Praveen, KT, Kudlur, SNC, Hanabe, RP, Egbewunmi, AT. Staff attitudes to smoking and the smoking ban. Psychiatr Bull 2009; 33: 84–8.
11 Campion, J, Checinski, K, Nurse, J, McNeill, A. Smoking by people with mental illness and benefits of smoke-free mental health services. Adv Psychiatr Treat 2008; 14: 217–28.
12 Brown, S, Barraclough, B, Inskip, H. Causes of the excess mortality of schizophrenia. Br J Psychiatry 2000; 177: 212–7.
13 Lawrence, D, Mitrou, F, Zubrick, SR. Smoking and mental illness: results from population surveys in Australia and the United States. BMC Public Health 2009; 9: 285.
14 Hughes, JR. Effects of abstinence from tobacco: valid symptoms and time course. Nicotine Tob Res 2007; 9: 315–27.
15 Cohen, S, Lichtenstein, E. Perceived stress, quitting smoking, and smoking relapse. Health Psychol 1990; 9: 466–78.
16 Lawn, S, Pols, R. Smoking bans in psychiatric inpatient settings? A review of the research. Aust NZ J Psychiatry 2005; 39: 866–85.
17 Berlin, I, Chen, H, Lirio, C. Depressive mood, suicide ideation and anxiety in smokers who do and smokers who do not manage to stop smoking after a target quit day. Addiction 2010; 105: 2209–16.
18 Marteau, TM, Munafò, MR, Aveyard, P, Hill, C, Whitwell, S, Willis, TA, et al Trial protocol: using genotype to tailor prescribing of nicotine replacement therapy: a randomised controlled trial assessing impact of communication upon adherence. BMC Public Health 2010; 10: 680.
19 Marteau, TM, Aveyard, P, Munafò, MR, Prevost, AT, Hollands, GJ, Armstrong, D, et al Effect on adherence to nicotine replacement therapy of informing smokers their dose is determined by their genotype: a randomised controlled trial. PLoS ONE 2012; 7: e35249.
20 Marteau, TM, Bekker, H. The development of a six-item short-form of the state scale of the Spielberger State-Trait Anxiety Inventory (STAI). Br J Clin Psychol 1992; 31: 301–6.
21 Court, H, Greenland, K, Margrain, TH. Measuring patient anxiety in primary care: Rasch analysis of the 6-item Spielberger State Anxiety Scale. Value Health 2010; 13: 813–9.
22 Tluczek, A, Henriques, JB, Brown, RL. Support for the reliability and validity of a six-item state anxiety scale derived from the State-Trait Anxiety Inventory. J Nurs Meas 2009; 17: 1928.
23 Hughes, JR, Keely, JP, Niaura, RS, Ossip-Klein, DJ, Richmond, RL, Swan, GE. Measures of abstinence in clinical trials: issues and recommendations. Nicotine Tob Res 2003; 5: 1325.
24 Ferguson, J, Bauld, L, Chesterman, J, Judge, K. The English smoking treatment services: one-year outcomes. Addiction 2005; 100 (suppl 2): 5969.
25 Heatherton, TF, Kozlowski, LT, Frecker, RC, Fagerstrom, KO. The Fagerstrom Test for Nicotine Dependence: a revision of the Fagerstrom Tolerance Questionnaire. Br J Addict 1991; 86: 1119–27.
26 Spielberger, CD. State-Trait Anxiety Inventory (Form Y). Consulting Psychologists Press, 1983.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
Please enter your name
Please enter a valid email address
Who would you like to send this to? *
×

Metrics

Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed

Change in anxiety following successful and unsuccessful attempts at smoking cessation: cohort study

  • Máirtín S. McDermott (a1), Theresa M. Marteau (a2), Gareth J. Hollands (a2), Matthew Hankins (a3) and Paul Aveyard (a4)...
Submit a response

eLetters

Hidden consequences of study design

Neil M Armstrong, Hon. Fellow
01 February 2013

The cohort study of people attempting to quit smoking described by McDermott et al has major implications.1 People with psychiatric disordershave a life expectancy of around 20 years lower than people without such adisorder and much of this loss is attributed to cigarette smoking. Popularbeliefs that smoking is an effective anxiolytic appear to form a barrier to health professionals to recommend quitting. There is evidence that people with psychiatric disorders are less likely than other smokers to beoffered cessation advice. So I was disappointed that the absence of a qualitative element to the study was not noted as a significant limitation. Measuring outcomes without gathering qualitative data can makestatistical findings difficult to interpret, particularly when discussing potential causal mechanisms.2 Here, an exclusive reliance on quantitative data appears (1) to have led to a limited use of the data and (2) encouraged an assumption that the cohort is universally representative.

The authors propose that a reduction of anxiety amongst people who have successfully quit smoking might be accounted for by reference to withdrawal symptoms. They observe that people 'smoke to stave off withdrawal symptoms, which include anxiety. By stopping smoking and removing these repeated episodes of anxiety, we might expect an overall reduction in reporting of anxiety, as observed.' This is the only causal mechanism discussed in a favourable light and only one other possible causal mechanism is discussed. 'There is no obvious causal mechanism otherthan those who relapse feeling concern arising from the continuing health risks of their smoking. However, we might expect this concern to return tobaseline levels relatively soon after relapse.' This seems rather speculative. Why should we assume that anxiety returns to baseline (or, indeed, assume that there is a baseline level of anxiety about such things)?

Health anxieties are an empirical phenomenon that requires investigation. In this case there might be other candidates for a causal role in generating anxiety in smokers such as stigma, or a sense of weakness of the will. Equally, there might be something in the experience of successful cessation that reduces anxiety. It is difficult to access this without qualitative methods. Ethnographic methods are probably well suited here, as rich and in-depth data are required.3

A wholly quantitative study design perhaps encourages universal conclusions because localised factors are better captured by qualitative means. Here the authors state that 'The belief that smoking is stress relieving is pervasive, but almost certainly wrong.' This might be true for the cohort, but it only holds more generally if we are confident that the cohort is representative of most human populations. Such a confidence here looks secure because the sole proposed causal mechanism - withdrawal - is universal. But I have suggested that we cannot assume this, and that it is an unintended consequence of the study design that it seems a safe assumption. Other mechanisms might not intrinsic to smoking and cannot be assumed to be evenly distributed across human populations. The physical risks of smoking may be uniform, but the consequences on anxiety may not be.

1 McDermott MS, Marteau MM, Hollards GJ, Hankins M Aveyard P. Change in anxiety following successful and unsuccessful attempts at smoking cessation: cohort study. Br J Psychiatry 2013; 202: 62-67.

2 Craig P, Dieppe P, Macintyre S, Mitchie S, Nazareth I, Petticrew M.Developing and evaluating complex interventions: the new Medical research council guidance. BMJ 2008: 337:a1655

3 Reeves S, Kuper A, Hodges BD. Qualitative research methodologies: ethnography. BMJ 2008; 337:a1020.

... More

Conflict of interest: None declared

Write a reply

Change in anxiety following successful and unsuccessful smoking cessation

Manjeet S. Bhatia
01 February 2013

This is an important cohort study bursting the myth that smoking is astress reliever. However, the implications of the study should be interpreted in view of some limitations. Firstly, the reason of initiation,continuation and stopping of smoking along with the personalityprofile of patient is important; Secondly, the association of psychiatric morbidity at initiation, maintenance and at time of stopping smoking requires consideration; Thirdly, analysis was done in follow up at 6 months and not more frequently as there is change in stress level and also, symptom pattern of a psychiatric disorder within six months;Fourthly,the groups were not analysed according to drug and dose ofNicotine Replacement Therapy; and lastly, the intake of other stimulants (i.e. caffeine)or drugs (especially SSRIs) not mentioned.

... More

Conflict of interest: None declared

Write a reply

×

Reply to: Submit a response


Your details


Conflicting interests

Do you have any conflicting interests? *